Psych Rotation: Do's and Don'ts

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My tendency with patients has always been to want to listen to them, to believe them, or at least their experiences. This led to me realizing during my first year of med school that I would be a psychiatrist. My ease and sense of belonging during my third year rotation solidified my choice.

As a second year psychiatry resident at Mt. Sinai Beth Israel, my training from that point until now has deepened and informed those innate tendencies. For example, did you know that one psychoanalytic explanation for the mechanism of much of psychosis is that people have permeable ego boundaries, that they have trouble distinguishing where they end and others begin? That's why they fear that others can read their minds and know their darkest secrets. Imagine what a frightening experience that must be! At the end of the day, it still all comes down to empathy and respect.

I say all of this mostly to explain why the post below is perhaps more serious and sincere than you were expecting. It'd be easy to fill a post with funny stories, but as an advocate for people with mental illness, I have a more important message to share.

Before I get to that though, let me speak as a resident. What I would expect from you if you rotated through our unit and knew you weren't going into psychiatry is simple:

1. Be respectful of the patients and uphold their dignity always.

2. Be able to do the mental status exam and properly use its terminology (e.g. "psychotic" colloquially means "murderous" but something entirely different in this field. Be able to explain what makes a particular patient psychotic).

3. First Aid for the psychiatry clerkship is the only book I think you need. It’s written at your level. Will it get you the score you want on the shelf? Who knows? Know the drug classes and their side effect profiles. Know child development. Know anything medical or developmental that causes confusion, mental retardation, or learning difficulties. Then pray. But in terms of what I’d want from you, I wouldn’t expect you to read anything outside of this book. (Of course, if you have UWorld, do the psych questions too. They’re helpful, but not sufficient for the rotation.)

4. Know the major types of psychopathology with which you'll come in contact—e.g. mood disorders, psychosis, anxiety, personality, substance, etc. Know which are treated inpatient, and how to describe them when calling a consult (essentially, know what a psychiatrist would most want to know about your patient before caring for him or her).

5. Most importantly, learn how to deal with the "difficult" patient, because you will have that experience all the time. Learn to listen, reflect, validate, understand and negotiate. No matter what field you go into, it will make your job immensely easier, and it is the mark of the most beloved physicians amongst patients and colleagues alike.

Now on to the DOs and DON'Ts...

Don’t laugh at the patients.

Do laugh with the patients at their illness.

The latter is a tough thing to do, and if you can’t pull it off, don’t try. But PLEASE do not ever be disrespectful of the patients. They deserve your respect as much as every other patient and are more disenfranchised and marginalized from proper medical care than just about everyone else. They did not choose to be ill. What’s worse, they have an illness that’s stigmatized, and for which they’re blamed. In psychiatry, there’s much disagreement about whether one should always keep a poker face or if it’s okay to laugh at the things patients say. I believe the latter. What’s important is that you don’t do anything that hurts the tenuous alliance you form with your patients.

Don’t confront patients about delusions.

Do express curiosity or confusion about them.

This also goes along with preserving the alliance. These patients are used to and sensitive about being doubted and contradicted, so don’t go and tell them that what they’re thinking is wrong, or that they’re psychotic. Ask, in the most innocuous way you can, for clarity. Tell them that you’re confused. Be non-judgmental and innocent. “Are you sure __________ is the president? I could have sworn __________ was running the country.”If the response you get is, “That’s what they want you to think!” then you have the information you needed without attempting to gain some sense of superiority over the patient, or making him feel judged, abandoned, or inferior.Be careful with your language. Starting questions with “Why…” puts the patient in a defensive position. Instead, put it back on yourself and say, “I’m not clear…” “I’m confused about something you said…” etc.

Don’t be afraid.

Do be careful.

This is like that old saying, “Trust in God, but lock your door.” People have this view of psych floors as being pure, violent chaos. Generally, the patients are too disorganized to be stalking and planning attacks on you. When they strike out, it’s usually out of fear—being psychotic is a terribly frightening existence. And by all means, be afraid. You can’t change how you feel. But think to yourself that the person you’re talking to is probably not choosing to be that way, that he’s not trying to scare you, but is in fact scared. Feel the fear, but don’t show it. Focus on the patient’s feelings and work to assuage them. Be kind, gentle. Don’t be defensive if a patient accuses you or other staff of persecuting him. Instead, empathize and reassure him.

“Omigod, Mr. M, that’s terrible that you feel they’ve been poisoning you and experimenting on you here! But I know these people and I can’t imagine that they’d ever do that. You know how they said you have paranoid schizophrenia? I think that might be what makes you feel this way—it’s because of your illness. We give you the same food and medicines as everyone else, and we want nothing more than for you to get better and go home.”

Don’t think that this spiel is going to cure your patient. The words are less important than your sentiment, empathy, and, especially, your tone. Patients who are psychotic don’t have the executive oversight and modulation from the cerebral cortex that you and I have. Also, they're primarily driven from more primitive parts of their brain. If you look scared or angry or frustrated, they’re likely to feel that they have reason to feel the same things, and might respond to those feelings without understanding why (or their psychotic processes will give psychotic explanations for why they’re feeling those things).So no matter what happens, try to keep calm, to exude a sense of being in control and unfazed. It will not only keep things in control, but also put your patients at ease.

And finally, don’t put yourself in danger’s way, especially with patients who’ve had a history of violence or antisocial traits. Talk to them in open spaces, keep yourself between them and the door, let staff members know if you’re going to go and interview them. Trust the guidance of the staff, and don’t be afraid to ask for help. If you’re being backed down against a wall, use a technique we want our patients to learn: Use your words. When our patients are scared or angry, they can tend to act out, to scream, throw a tantrum, or use their fists. We tell them to say what they’re feeling and why with “I” language: “I feel _____ when you _____ because _____.” Or something similar.

“Mr. M, we can keep talking, but I don’t feel comfortable with you standing so close to me. I need you to take two steps back and give me some space.”

Don’t revel in catching your patients in lies.

Do realize that we’re multifaceted people and realize the importance of collateral information.

This is probably my biggest pet peeve with med students and residents rotating through psych, and other services working with us. There are many reasons why we all misrepresent ourselves. Denial, distrust, paranoia, mania, delusions, self-interest. Never are we, as providers, having people interview us and then matching our answers about ourselves with those of our family members and other providers. It’s a very vulnerable position to be in, and we should not take advantage of it. Our goal is to understand our patients holistically. If our patients misrepresent themselves, our job is to understand why. We should realize that everyone has some agenda in how he or she represents the patient, including family members and other providers. Reserve judgment and focus on the big picture. Remember that your goal is to help the patient, not to find him out to be a liar.

Don’t be so easily offended.

Do set limits.

Patients can say some really messed up things. You might be called a racist by a psychotic patient who’s feeling scared, trapped or mistreated. You might be called a failure by a manic, narcissistic or entitled patient who feels let down (this is likely to happen on any medical unit). You might be cursed at, threatened, or called any variety of slurs by a patient who is angry for whatever reason. Try and use it to learn about the patient and to not make it about you.After all, you’re also likely to be given extravagant (and maybe inappropriate) praise on a psych unit too, and that has as little to do with you as the criticism (the patient might be a happy manic, or just looking for help to be discharged).

That said, while you don’t have to get mad, you don’t have to tolerate it either. You’re well within your rights to say, calmly, “Excuse me Mr. M, but that kind of language is not going to be tolerated here,” or, “You will not speak to me that way. This conversation is over until you can speak respectfully.” Even psychotic patients may take liberties with inappropriate language/behavior, and can respond to clear language and limit-setting.

Finally, do have fun.

Psych is often a very fun, entertaining rotation for a lot of students, with some of the best stories that they’ll have to share with others. Just off the top of my head, I remember a patient of mine who said he could give his girlfriend orgasms with his mind. We had a lot of fun fantasizing about what we’d do with a superpower like that (I would use it on would-be muggers and superiors who are demeaning toward me in public. The way I see it, nobody gets hurt!).

A good sense of humor is essential in this field. Sure, there's so much ridiculousness that makes us want to laugh. But there are also a lot of things that can be quite draining: suicide, depression, help-rejection, committing and treating patients against their will as they accuse you of experimenting on and poisoning them. Humor helps us to process, to vent, and to keep things light. Just be kind and compassionate to your patients, treat them with respect, and be able to differentiate between the illness and the person. If you can do that, you’ll be able to have a good time while also making a difference.

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Birju has specialized in tutoring the MCAT since 2003. He served 2 years with Princeton Review, a year with Bright Future Learning Center (NJ), 7 years with Examkrackers, and roughly 10 years as an independent private tutor, including the last 3 with MedSchool Tutors. Birju is graduating from UMDNJ-NJMS and is now in his second year of psychiatry residency at Einstein-Beth Israel Medical Center.